Braz. Brazil. Mental Health and Drug Problems in Brazil 1/13/2014. Brazil. Dartiu Xavier da Silveira. Sao Paulo. January, 10, 2014

Transcription

1 Mental Health and Drug Problems in Brazil Dartiu Xavier da Silveira Sao Paulo January, 10, 2014 Braz Brazil Brazil North Northeast Central Southwest South 1

2 Brazil The fifth largest country in the world, both in geographical area and in population, with over 193 million people. Bounded by the Atlantic Ocean on the east, Brazil has a coastline of 7,491 km. Brazil was a colony of Portugal from 1500 until 1808, when the Portuguese Empire was transferred from Lisbon to Rio, after Napoleon s invasion. Independence was achieved in 1822 with the formation of the Empire of Brazil. The country became a presidential republic in Brazil has one of the world s fastest growing economy. Home of a variety of wildlife, natural environments, and extensive natural resources. Noronha Island Sao Paulo 2

3 Closing the Mental Health Gap in Brazil: Challenges for a Universal Health Care System (SUS) From Hospitals to Communities: Change in MH expenditure Community mental health services Psychiatric Hospitals Expanding Coverage: Getting closer to Communities : From 424 to 1981Community Mental Health Services (CMHC) Geographical expansion of coverage by CMHC 3

4 Closing the Mental Health Gap: Working with Primary Care 1. Implement mental health care as an integral element of primary health care services. Mental Health Coverage (2011) Primary Care Coverage (2013) Closing the Mental Health Gap: Quality and Comprehensiveness of Care 2. Expand the coverage offered by community mental health centres while improving the quality of care offered by them. 3. Expand the treatment of drug related disorders within local networks of mental health services. Some barriers and challenges The primary care system sometimes is not properly understood, being frequently considered as a kind of magic solution, as if all answers would lay on there. Human resources: Let s take a professional that has chosen to be a general physician, that has dedicated 10 years of his education at a medical school to become a physician trained in internal medicine, and suddenly we want him to learn a sort of general psychiatry where he feels himself quite uncomfortable 4

5 So what should we do then? Primary Care physicians are quite sensitive and compassionate with patients suffering However, they often try to alleviate this suffering just by treating a disease (or illness). That is a quite confusing issue since the medical concept of disease is absolutely different from the patient s perspective of his suffering So what should we do then? Establishment of a network of mental health facilities encompassing distinct models of intervention In most cases, an associated psycho social approach is mandatory Human resources: Specific training for personal, tailored to fit differentiated levels of the required complexity of the available services São Paulo Mental Health Survey SPMHS is a cross sectional population based epidemiological study of psychiatric morbidity, assessing a probabilistic sample of household adult residents. 5,037 adult residents in the SPMA, using the World Mental Health Survey Version of the Composite International Diagnostic Interview. Response rate was 81.3%. Viana, MC & Andrade, LH,

6 São Paulo Mental Health Survey Results Lifetime prevalence for any disorder 44.8% Estimated risk at age 75 years 57.7% Comorbidity frequent Viana, MC & Andrade, LH, 2012 São Paulo Mental Health Survey Results Most prevalent disorders: Major Depression 16.9 % Anxiety Disorder 28.1% Alcohol Abuse 9.8% Viana, MC & Andrade, LH, 2012 São Paulo Mental Health Survey Results Characteristics: Early age of onset Late age of onset Phobic and Impulse control Mood Disorders Substance Use Gender (Men) and Low Education Viana, MC & Andrade, LH,

7 Brazilian Household Survey 108 Cities with more than 200,000 unhabitants Alcohol Dependency 12,3% Poercentage Carlini, E, 2010 (CEBRID) How addictive are drugs? Anthony, J., 2004 (National Institute of Drug Abuse) How addictive are drugs? 7

8 How addictive are drugs? How addictive are drugs? Ever increasing use in Latin America 8

9 Estimate of the number of crack cocaine users in Brazil (2013) Princeton University and Fundação Osvaldo Cruz (FIOCRUZ) NSUM Network Scale up Method 25,000 persons interviewed Bastos, FI (in press) Pattern of crack use: Regular use 25 times in the previous 6 months period (PAHO) RESULTS 0.81% (CI95%): ), corresponding to 370,000 regular users Illicit drug users (except cannabis): 2.28% (CI95%: ) 1 million users Crack cocaine users represent 35% of all illicit drug users Who are the crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed (crack users) Bastos, FI (in press) Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed AGE 9

10 Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed SEX Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed ETHNICS Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed EDUCATIONAL BACKGROUND 10

11 Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed OTHER DRUGS USE Tobacco 92.1 Alcohol 83.9 Cannabis 76.1 Cocaine 52.2 Inhalants 26.4 Benzodiazepines 14.6 Ecstasy/MDMA 3.0 LSD 2.0 Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed OTHER RELEVANT INFORMATION Long time users 91 months (~ 8 years) Amount of crack used 9 to 16 rocks of crack Sharing paraphernalia 67.6 to 74.2 % Acute intoxication (over doses) 7.8 % (last month) Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed OTHER RELEVANT INFORMATION Sexual Behavior Recent condom use never 39.5 (CI95%: ) Tested for HIV never 53.9 (CI95%: ) Gender related issues Drugs for sex Women 29.9 % versus 1.3 % Men Sexual violence Women 44.5 % versus 7.0 % Men 11

12 Who are crack cocaine users in Brazil? Fundação Osvaldo Cruz (FIOCRUZ) TLS Time Location Sampling 7,381 persons interviewed OTHER RELEVANT INFORMATION Comorbid prevalences: HIV 5.0 % versus 0.6 % (general population) Hepatites C 2.6 % versus 1,38 % (general population) Tuberculosis 1.7 % Brazil Alcohol Cocaine Other Marijuana snorted smoked (crack) Amphetamines MDMA, ketamine, etc Brazil Legal x Illegal Drugs Hidden populations (vulnerabilities) Policies Brazilian government (Minist. of Health) Outward treatment focused on Harm Reduction Strong resistance to HR Strategies Coercitive approaches (involuntary/compulsory hospitalization) 12

13 Incarceration in America and Drug Price Brazil Law and General Health System Licit x Illicit drugs Drug user X Drug Dealer (Ambiguous) Drug user xdrug Addict (Ambiguous) Blame the user Human rights Prohibition LATIN AMERICA IMPORTANT CHANGES IN 2013 Contrasting with what is happening now in other countries 13

14

15

16 War on Drugs What happened 40 years later(today)? Ever increasing use, directly benefiting crime. Negative secondary effects: mass encarceration, hundreds of thousands homicides (related to war on drugs), widespread corruption, HIV/AIDS increasing, Human rights violation. Problems More rhetorical heat in debate than real scientific evidence. This debate has been strongly affected by the reductionist biological paradigm that underlies contemporary psychiatry when approaching addictive behaviours. Harm reduction strategies tend to be rejected. Problems Distortions in this debate have adversely affected public policies. 16

17 Media and Moral Panic: A Quantitative exploration of drug fatality reports in the popular press. What SHOULD be done? Failure of Prohibition Failure of the abstinence centered model of treatment Policies just don t care about drug users (neglected) Mass criminalisation Mass medicalization Generally drug users tend to be considered... Criminals Mental cases Sinners 17

18 Disease, Ilness, Distress, Suffering Health professionals are not prepared to deal with patient s suffering But we must remember that the main motivation for a patient to look for health care is his/her suffering Specific training for such a comprehensive approach is generally still lacking Suffering, beyond mental illness To be compassionate and empathetic does not mean we have a good understanding of what suffering is, how it works, why it emerges... And, if we could have that understanding we would be able to act in a more effective way Dartiu Xavier da Silveira, M.D., Ph.D. Sao Paulo Medical School Federal University of Sao Paulo, Brazil dartiu@terra.com.br